Advance care planning in palliative care - systems and silos. Plus new Medical Treatment Planning and Decisions Act 2016

Transcription

1 Advance care planning in palliative care - systems and silos Plus new Medical Treatment Planning and Decisions Act 2016

2 Learning objectives 1. How is advance care planning relevant to palliative care? 2. Silos and systems 3. Implications of the new legislation for palliative care health professionals, health services and patients and families

3 Palliative care 'an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (WHO)

4 Dying in Australia >150,000 deaths a year, 6.7 deaths per 1000 people 2/3 in those over 75 years of age Just under half of those who died as hospital inpatients had involvement from or care from palliative care About half of deaths occurred in hospital

5 What is dying well?

6 Health service utilisation in last year of life Hospital admissions increase in last year of life Average 8 per person Average 44 inpatient days (Rosenwall) Only half people die in place of choice Half die in hospital Push to improve advance care planning and end of life decision making

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8 Mrs Elsa Barnes Mrs Barnes is an elderly former teacher with metastatic non small cell lung cancer Multiple teams involved Cancer centre (med onc, rad onc, pall care) Primary care (GP and practice nurse) RDNS for dressings to leg wounds Community palliative care Mrs Barnes becomes unwell and calls the ambulance which takes her to ED Where is the advance care plan?

9 Systems and silos Where is the advance care plan? Acute care Community palliative care General practice/primary care Aged care Inpatient palliative care ambulance Consultation palliative care

10 Role of palliative care in advance care planning Should be a high priority in community and outpatient palliative care Enhances place of choice to die Room to improve communication of advance care plans between settings (silos) Need to participate in embedding in systems

11 Advance care planning made easy If you were very unwell, and could not talk to the doctors about what medical treatments you would and would not want, WHO would you want to speak for you? (medical treatment decision maker) And WHAT would you want them to say? (advance care directive, statement of choices, refusal of treatment certificate) ACP - Appoint an agent _ Chat and communicate _ Put it on paper

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13 Headlines of MTPD Act The Act ensures that medical decision making is more in line with contemporary views and how people make decisions Two types of directives Instructional Values Medical treatment decision maker Support person

14 Key changes People can make decisions about future medical conditions People can consent to treatments as well as refuse A support person can help a person to make decisions for themselves Advance care directives will have statutory recognition

15 I want a pony An advance directive may not request a procedure that is unlawful or would require an unlawful act to be performed Or a procedure that would mean the health practitioner contravenes professional standards or ethics* Nothing in this Act requires a health practitioner to administer a futile or non-beneficial medical treatment or medical research procedure to a person.

16 Health professional s obligations Nothing affects your duty of care before giving medical treatment to a person without decision making capacity, you must make reasonable efforts in the circumstances to find out if they have Advance directive Medical treatment decision maker If you don t it is unprofessional conduct

17 Palliative care Administering palliative care A health practitioner may administer palliative care to any person who does not have decisionmaking capacity for that care despite any decision of the person's medical treatment decision maker, but in making a decision to administer that care must (a) have regard to any preferences and values of the person, whether expressed by way of a values directive or otherwise; and (b) consult with the person's medical treatment decision maker (if any).

18 Who is the person s MDTM? The legally appointed MDTM* Guardian appointed by VCAT* The first* of Spouse or domestic partner Primary carer First of (oldest) adult child, parent, adult sibling, * reasonably available, willing and able

19 Giving effect to an advance directive Mr Lee is a 58 year old school teacher with metastatic lung cancer He is brought in to the palliative care unit by his family for management of dehydration, confusion and constipation He has an instructional directive that he s not for CPR, intubation, IV therapy, or life prolonging treatment His family want you to investigate for hypercalcaemia Thoughts?

20 Giving effect to an advance directive Same scenario.. His wife is his medical treatment decision maker His advance directive is a values directive Mrs Lee insists on investigations and treatment

21 Giving effect to an advance directive You must give effect to an instructional directive You must consider a values directive If you don t it forms unprofessional conduct. The MTDM must make the decision that the MTDM reasonably believes the person would have made

22 summary ACP who would you want to speak for you, and what would you want them to say? Has benefits for patients, families, and health systems We all have a role New legislation in Victoria carries increased obligations for health services and health practitioners

23 What should you ask a MTDM to consider? 1. Consider any valid and relevant values directive 2. Consider the preferences the person expressed and their circumstances 3. If not 1 or 2, Give consideration to their values (expressed or inferred) 4. Consider likely effects and consequences of treatment and alternatives 5. Act in good faith 6. Still not sure? Consider their personal and social wellbeing.

24 What is significant treatment? significant treatment means any medical treatment of a person that involves any of the following (a) a significant degree of bodily intrusion; (b) a significant risk to the person; (c) significant side effects; (d) significant distress to the person;

25 EOLCare vs palliative care End-of-life care: Includes physical, spiritual and psychosocial assessment, care and treatment delivered by health professionals and ancillary staff. It also includes the support of families and carers, and care of the patient s body after their death. People are approaching the end of life when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with: advanced, progressive, incurable conditions general frailty and co-existing conditions that mean that they are expected to die within 12 months existing conditions, if they are at risk of dying from a sudden acute crisis in their condition life-threatening acute conditions caused by sudden catastrophic events. Palliative care: an approach to treatment that improves the quality of life of patients and their families facing life-limiting illness, through the prevention and relief of suffering. It involves early identification and impeccable assessment and treatment of pain and other problems (physical, psychosocial and spiritual). Source: ACSQHC 2015.